Care, Custody, and Consent to Treat Form CARE, CUSTODY, & CONSENT TO TREAT Owner / Agent InfoWho is submitting this form?(Required) Owner Agent Name First Last PhoneAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Equine InformationName Breed Color Age Sex Male Female Reason for Admission Consent SectionConsent 1(Required) I Agree(Required)During the time that the horse is in custody of McKinlay & Peters Equine Hospital, McKinlay & Peters Equine Hospital shall not be liable for any sickness, disease, astray, theft, death or injury which may be suffered by the horse or any other cause of action, whatsoever, arising out of or being connected in any way with the hospitalization of said horse, except in the event of negligence on the part of McKinlay & Peters Equine Hospital, its agents, and/or employees. This includes, but is not limited to, any personal injury or disability that horse owner/agent may receive on the property. Any action or claim brought by Owner against McKinlay & Peters Equine Hospital for loss due to negligence must be brought within one (1) year of the date of such claim or loss occurs.Consent 2(Required) I Agree(Required)Owner/Agent fully understands the McKinlay & Peters Equine Hospital does not carry any insurance on hospitalized horses. If the horse is insured, it will be the responsibility of the owner to inform the insurance company of any sickness, disease, astray, theft, death or injury while in the care, custody & control of McKinlay & Peters Equine Hospital. All risks connected with the horse while in the care, custody & control of McKinlay & Peters Equine Hospital are to be borne by the Owner. McKinlay & Peters Equine Hospital strongly recommends equine mortality insurance be obtained applicable to the subject horse by Owner.Consent 3(Required) I Agree(Required)The standard of care applicable to McKinlay & Peters Equine Hospital is that of ordinary care of a prudent horse owner and not as a compensated bailee. In no event, shall McKinlay & Peters Equine Hospital be held liable to Owner for equine death or injury in an amount in excess of five thousand dollars ($5,000). Owner agrees to obtain equine insurance for any horse valued in excess of five thousand dollars ($5,000). Owner agrees to disclose this entire agreement to Owner's insurance company and provide McKinlay & Peters Equine Hospital with the company's name, address and policy number. Failure to disclose insurance information shall be at Owner's risk.Consent 4(Required) I Agree(Required)McKinlay & Peters Equine Hospital will make every effort to contact Owner/Agent in the event that a horse becomes ill and requires care. In the event that the Owner/Agent cannot be immediately reached, Owner/Agent authorizes McKinlay & Peters Equine Hospital to provide necessary care or treatment at the Owner's expense.Consent 5(Required) I Agree(Required)Owner/Agent agrees to retrieve the animal from the Hospital as soon as the animal is ready for release, upon notification from McKinlay & Peters Equine Hospital. Owner/Agent agrees to be responsible for any fees incurred as a result of a delay in retrieving the animal after receiving such notification. Pursuant to Washington law, failure to retrieve the animal within fifteen days of notification shall result in the animal being declared abandoned, at which point McKinlay Peters may dispose of the animal in accordance with RCW 16.54.020. Consent 5(Required) I Agree(Required)Owner agrees to hold McKinlay & Peters Equine Hospital harmless from any and all claims arising from damage or injury caused by owner's horse to anyone, and defend McKinlay & Peters Equine Hospital from any such claims. Owner agrees to disclose any and all hazardous or dangerous propensities of horse with McKinlay & Peters Equine Hospital.Signature(s) SectionI hereby state that I have read and understood this care, custody and control agreement and acknowledge receipt of a copy thereof. Owner Signature(Required)Owner Signature Date(Required) Month Day Year Agent SignatureAgent Signature Date Month Day Year Witness SignatureWitness Signature Date Month Day Year Equine Patient Doctor CAPTCHA Δ
